By Andrew Crim, CHCP; Pam McFadden, FACEHP; Leslie Allsopp, MSN MPH; Opeyemi Jegede, MPH; David A. Sterling, PhD, CIH; Kelly Zarwell, Dena Silva, CHCP
The Asthma 411 Pilot Program was implemented in one elementary school and one middle school during the 2013 to 2014 and 2014 to 2015 school years, with the goal of reducing the impact of asthma on children’s school experience and exploring the feasibility of expanding the initiative within the Fort Worth Independent School District. It was largely funded by independent educational grants from GlaxoSmithKline and Boehringer Ingelheim, with additional support from UNT Health Science Center’s School for Public Health and Office of Professional and Continuing Education.
Key program elements included:
- Partnering with a public school district to address a health concern that impacts attendance and healthcare costs.
- Provision of a consulting physician.
- Development of standing orders for the administration of nebulized albuterol to students with symptoms of respiratory distress and signed informed consent from their parents.
- Provision of necessary supplies and training for implementation of standing orders.
- Support for enhanced tracking of students with asthma and identification of those with signs of poor or deteriorating asthma management.
- Support for asthma self-management education for students and parents.
- Support for asthma awareness among school staff and administrators.
- Support for enhanced communication between school nurses, parents and healthcare providers.
- Professional development for school nurses and community healthcare providers.
Challenges to implementation and evaluation of the program included a lack of baseline data, a short pilot period and competing priorities within the school environment, especially to implementation of educational components of the program. The evaluation of the program indicated the following:
- Elimination of virtually all asthma-related 911 calls at both schools during school hours.
- Provision of 96 nebulized albuterol treatments to students, which prevented students from being sent home from school or requiring ambulance services.
- A positive response to the initiative from parents.
- The response was generally positive from nurses, but there was concern that availability of nebulized albuterol at school might be a disincentive for some families to obtain prevention-oriented care outside of the school. For this reason, availability of nebulized albuterol should be accompanied by support for linkages to comprehensive asthma care through a medical home, especially for children at risk for suboptimal management.
- No clinical concerns related to implementation of the standing orders identified.
- Documented parent communication more than doubled, and documented student asthma education services nearly tripled between year one and two of the program, without evidence of an increase in the average number of nursing visits per student with asthma.
- Evidence suggests that the average number of absences among students with asthma decreased between year one and year two of the program, and the attendance gap between students with and without asthma narrowed.
- Improvements in knowledge and competence across educational activities.
Additionally, a survey conducted during the first year of the program suggested that 19 percent of absences among students with asthma are related to their condition. Applying this to absence data from the two pilot schools for both years, data suggest that a total of 421 absence days and $12,209 in lost school revenues were asthma-related. These data indicate that program costs may potentially be offset by savings in reduced absences.
Asthma is among the most common chronic childhood conditions and remains the most prevalent cause of childhood disability.1 In Tarrant County, Texas, of children 0–14 years of age, approximately 75,500 have asthma. By age 9, fully 25 percent of the county’s children will have been diagnosed with asthma, with a disproportionate number of cases occurring among African American children.2 Multiple studies have shown that children with asthma have higher rates of absenteeism than their healthy peers.3, 4 Additionally, it is well documented that excessive school absences disrupt learning and are a strong predictor of premature school dropout.5 However, with appropriate diagnosis, education and management, asthma can be controlled, reducing absenteeism and healthcare utilization.6
Asthma 411 was introduced at the start of the 2013 to 2014 academic year as a pilot program in two schools in the Fort Worth Independent School District (FWISD) to evaluate the feasibility of dissemination within a school district in Tarrant County. The two schools, one elementary with grades K through five, the second a middle school with grades seven to eight, were selected based on high self-reported asthma prevalence, high number of minority students and the presence of school-based clinics as compared to other FWISD schools.
An essential measure to enhance school health services was the provision of a consulting physician who, in collaboration with the two school nurses and the FWISD Health Services director and head nurses, developed standing orders for administration of nebulized albuterol to students exhibiting respiratory distress. The standing orders were implemented for those students with signed parental permission. Nebulizers, albuterol aliquots and blood oxygen sensors were provided by the UNTHSC School of Public Health and were provided to both school nurses with appropriate education and training. These steps are consistent with recommendations to assure access to rescue medication at school.7
Additional program components designed to strengthen school-based asthma management included:
- Asthma education for school nurses and community-based healthcare providers.
- Measures to increase asthma awareness among administrators.
- Asthma self-management and educational materials for students and parent/caregivers.
- Enhanced tracking of students with asthma.
- Support for identification of students with asthma and elevated absenteeism or other indicators of deteriorating asthma control.
- Evaluation of these students by administration of Asthma Control Tests (ACTs).
- Communication of ACT results to parents and caregivers.
Evaluation and outcomes data were collected through multiple sources:
- Aggregate monthly reports: Provided by school nurses, these reports included information on the total number of asthma-related visits, children receiving rescue medication through the Asthma 411 standing orders and the provision of prevention-oriented services.
- De-identified electronic records: At the end of each school year, these records were provided by FWISD for each school, with data on self-reported asthma status, gender, race, age, grade, free or reduced lunch fee status and days absent.
- Surveys: During the first program year, a survey was conducted to better assess the impact of asthma on absenteeism. The school nurse or office staff attempted to contact each student with asthma who was absent on pre-selected days to determine if absence was due to asthma or some other cause.
- Cases presented during CME/CE activities: Educational activities used cases and other competence-based questions to assess providers’ improvement during live and online activities.
- 911 call data: MedStar911, the region’s emergency responder, historically provided call data related to asthma for the two schools.
Pilot Program Population
During the 2013 to 2014 and 2014 to 2015 academic years, the Asthma 411 Pilot Program served a predominantly African American and Hispanic population in Fort Worth, Texas. An estimated 84.4 percent of students in the pilot schools are from families with an income below 100 percent poverty and another 4.25 percent are from families living at 100-185 percent poverty. This is significant as urban residence, low-income and African American race are all factors associated with a higher prevalence of asthma and an increased risk of adverse outcomes.8
2013 to 2014 Survey to Estimate the Contribution of Asthma to Absences
Asthma is recognized to be a leading cause of school absences, and reduction of asthma-related absences was a goal of the Asthma 411 program. Because existing data collection within the schools does not allow for evaluation of absences due to asthma, a decision was made to conduct a survey to estimate the impact of asthma on school attendance. This survey was conducted from November 2013 through May 2014. Twice-monthly telephone calls were placed to the parent/guardian of all absent children identified as having asthma. The parent/guardian was asked if the child’s absence was due to asthma. At the elementary school, the school nurse conducted the survey and 76.9 percent of families were successfully contacted. Within the middle school, office staff conducted the survey and 70.8 percent of patents were successfully contacted. Results within the two schools were similar; among children with identified asthma whose parent/guardian was successfully contacted, 17.5 percent of absences were due to asthma at the elementary school, and 19.6 percent were due to asthma at the middle school. These estimates were then applied to the total absences among children with asthma during the 2013 to 2014 school year. Table 1 presents these results. These estimates indicate the impact asthma has on school attendance and lost school funds for these two schools, as well as potential impact of lost parental work days. It also suggests the potential benefit that may be derived from strengthened school-based asthma services. This information was shared with school nurses and administrators. The survey was not repeated during the 2014 to 2015, so that limited resources could be focused on identification of children with asthma and elevated rates of absenteeism or other indication of deteriorating asthma control.
Both administrators and school nurses expressed concern that limited resources would preclude the delivery of some services specified in the Asthma 411 program proposal. Nurses particularly expressed concern about their ability to provide asthma self-management education and Asthma Control Tests (ACTs) to students with evidence of poor or deteriorating asthma control due to time availability.
Despite these concerns, a substantial increase in prevention-oriented services was seen between the first and second years of the program. Documented parent communication more than doubled and student asthma educationservices nearly tripled between year one and two. While increases were seen in both schools, expanded provision of documented prevention-oriented services was particularly apparent at the middle school as shown in Figure 1. At approximately the mid-point of the 2014 to 2015 school year, the middle school nurse began to periodically monitor absences among children with asthma and provide ACTs to those for whom asthma was a contributing factor. ACT results indicting suboptimal management were provided to parents with a request that the children receive a healthcare evaluation and the ACT results be provided to the healthcare provider.
There are several important points to note from these data. Despite initial concerns about administration of nebulized albuterol through the consulting physician’s standing orders, there were no negative clinical issues identified across the study period; nurses reported that the availability of nebulized albuterol enhanced their ability to address the needs of children with identified asthma, parents responded positively and 911 calls were virtually eliminated. The availability of nebulized albuterol through Asthma 411 standing orders was beneficial for students with asthma who did not have medication at school, including the following: those who had not obtained HCP permission, those with HCP permission but who did not bring in medication, those who brought in medication but ran out, and those who required nebulized treatments but whose families could not obtain a second nebulizer for school use. Each of these points is discussed in greater detail below.
Reports indicate that during the academic year preceding the initiative (2012 to 2013,) there were 19 asthma-related 911 calls placed from the schools. With implementation of nebulized albuterol through standing orders, 911 calls for asthma from the schools were virtually eliminated, with only one made the following two school years. Nurses provided nebulized albuterol to students with symptoms of respiratory distress a total of 96 times during the study period. In only two instances, nurses indicated the student returned to class and completed the school day without difficulty. In the remaining instances, the student was dismissed home with the parent/guardian. If nebulized albuterol through 411 standing orders not been available, nurses report that in all 96 cases the parent/guardian would have been called to take the student home or an ambulance call would have been placed to obtain emergency services, and the student would have been recorded absent based on time-of-day of event.
It should be noted that less than one-third of children with asthma had rescue medicine available at school. Among those with healthcare provider permission to have medication at school, between 25 and 32 percent did not have the medicine available. Nurses at both schools report that students frequently run out of medication or misplace self-carry inhalers. For students whose healthcare providers stipulate nebulized albuterol should be available, nurses report that many families do not have access to two compressors as would be necessary for treatments to be given at home and school. Ready access to rescue medications at school is among the recommendation of the National Asthma Education and Prevention Program (NAEPP).7 Despite the reservations expressed prior to program implementation by both nurses, at the close of the program there was a consensus that the availability of nebulized albuterol through standing orders had been of substantial benefit to students and had enhanced the ability of nurses to provide necessary care, avoid 911 calls andreduce the impact of asthma on children’s school experience. However, there was concern that, for some families, the availability of nebulized albuterol at school might be a disincentive for some families to obtain prevention-oriented care outside of the school. For this reason, availability of nebulized albuterol should be accompanied by support for linkages to comprehensive, prevention-oriented care through a medical home, especially for children at risk for suboptimal management.
Finally, there were initial concerns that limited resources and existing responsibilities would preclude the administration of prevention-oriented services, such as asthma education, administration of ACTs for students with indications of deteriorating control, and communication with parents and healthcare providers. However, substantial increases were seen in the provision of these services without a documented increase in the average number of asthma-related nurse visits per student with identified asthma.
Absences Among Students Identified to Have Asthma
Reducing absences due to asthma was a primary goal of the Asthma 411 pilot project. Table 4 presents the mean absences adjusted for days of enrollment for each of the pilot study years and for children with and without asthma. As noted in Table 3, children with identified asthma had higher mean and median averages than children without asthma in both of the two study years, and this difference was statistically significant. The difference between the mean number of absences among children with and without identified asthma decreased 24 percent from year one to year two of the program, from 5.1 days to 3.8 days, and the median difference fell from 4.1 to 2.0 days. It should also be noted that the mean and median absences fell among children with asthma from the first to second year of the pilot program, but mean and median absences increased among children without identified asthma during this time.
An additional analysis was done that included only those students who were identified as having asthma both years and those that were identified with asthma neither year. A comparison was made between the mean number of days absent based on asthma status. It was noted that there was an especially wide range of absences for all students. Because outlier values are likely to skew the mean and may be expected to represent factors that are not amenable to modification through the pilot initiative, analysis was done both with and without far outlier values as defined in the SASTM statistical software that was used for analysis. Results are presented in Table 4.
There are several important points to note about the absence data from the pilot project. First, among all students, the overall absence rates are high in comparison to national estimates. Additionally, the excess in absences among those students with identified asthma is high in comparison to national averages. Given the potential for underreporting of asthma discussed above, from 5 to 10 percent of those in the no asthma category may indeed have asthma. Both observations suggest this is a population for whom absence intervention, especially for asthma, may provide important benefits to students and the district as a whole. To learn more about the Asthma 411 expected outcomes and measures. To learn more about the Asthma 411 expected outcomes and measures, click here for the full table.
Secondly, despite the lack of baseline data from the year prior to the pilot program, limitations in implementation of planned educational interventions, and high student mobility, with only 52 students identified as having asthma and enrolled in pilot schools during both program years, data suggest a reduction in absences from year one to year two that is greater for students with asthma than without asthma.
- Akinbami LJ, Moorman JE, Garbe PL, Sondik EJ. Status of childhood asthma in the United States, 1980–2007. Pediatrics. 2009;123(Supplement 3):S131-S145.
- Cook Children’s. Community wide children’s health assessment and planning survey: Selected survey findings on asthma. https://www.centerforchildrenshealth.org/SiteCollectionDocuments/CCHAPSReports/CCHAPSSpecialReport-Asthma.pdf. Updated 2008. Accessed 11/08, 2015.
- Moonie SA, Sterling DA, Figgs L, Castro M. Asthma status and severity affects missed school days. J Sch Health. 2006;76(1):18.
- Moonie S, Sterling DA, Figgs LW, Castro M. The relationship between school absence, academic performance, and asthma status. J Sch Health. 2008;78(3):140-148.
- Balfanz R, Byrnes V. The importance of being there: A report on absenteeism in the Nation’s public schools. Baltimore, MD: Johns Hopkins University School of Education, Everyone Graduates Center, Get Schooled. 2012:1-46. http://edsource.org/wp-content/uploads/FINALChronicAbsenteeismReport_May16.pdf. Accessed 11/16/15.
- Clark NM, Brown R, Joseph CL, Anderson EW, Liu M, Valerio MA. Effects of a comprehensive school-based asthma program on symptoms, parent management, grades, and absenteeism. CHEST Journal. 2004;125(5):1674-1679.
- National Heart Lung and Blood Institute National Asthma Education and Prevention Program. Expert panel report 3: Guidelines for the diagnosis and management of asthma. 2007; 2015(11/10).
- Akinbami LJ, Moorman JE, Simon AE, Schoendorf KC. Trends in racial disparities for asthma outcomes among children 0 to 17 years, 2001-2010. J Allergy Clin Immunol. 2014;134(3):547-553. e5.
- National Survey of Children’s Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Accessed 12/14/15 childhealthdata.org.
- Pike EV, Richmond CM, Hobson A, Kleiss J, Wottowa J, Sterling DA. Development and evaluation of an integrated asthma awareness curriculum for the elementary school classroom. Journal of Urban Health. 2011;88 (1):61-67.
- SAS 9.3 (2010) SAS Institute Inc., Cary, NC, USA